388708_Well Construction - GW1_20100101

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2436-A
1. WELL CONTRACTOR:
DERRICK HEATH SAWYERS
Well Contractor (Individual) Name
CLYDE SAWYERS AND SON WELL DRILL
Well Contractor Company Name
14885 HWY 209
Street Address
HOT SPRINGS NC 28743
City or Town State Zip Code
( 828) 665-2022
Area code Phone number
2 WELL INFORMATION.
WELL CONSTRUCTION PERMIT# 2010-00470
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable)_
3. WELL USE (Check Applicable Box) Residential Water Supply if
DATE DRILLED 10-04-10
TIME COMPLETED 4:00 AM 0 PM 11
4. WELL LOCATION:
ciTY candler couNTY BUNCOMBE
60 fincher lane candler. nc 28715
(Street Name, Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING (check appropnate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 35 ° 33 ' 5,301 0000" DMS OR 3x XXXXXXXXX DD
LONGITUDE 82 ° 40 6,345 0000 " DMS OR 7x XXXXXXXXX DD
Latitude/longitude source E 3PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL OWNER
MARGARETT BURNETT
Owner Name
60 fincher lane
Street Address
candler NC 28715
City or Town State Zip Code
(828 ) 665-3062
Area code Phone number
6. WELL DETAILS.
a TOTAL DEPTH. 235
b. DOES WELL REPLACE EXISTING WELL? YES r' NO ❑
c. WATER LEVEL Below Top of Casing 60 FT FT
(Use "+" if Above Top of Casing)
d TOP OF CASING IS +1 FT Above Land Surface*
*Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 0118
e YIELD (gpm) 40 FT METHOD OF TEST ria
f. DISINFECTION. Type PILLS Amount 16
(-
g WATER ZONES (depth)
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7 CASING: Depth Diameter Weight Material
Top 0 Bottom 52 Ft 6 25" #21 PVC
Top Bottom Ft
Top Bottom Ft
8 GROUT Depth Matenal
Top O Bottome352 Ft CEMENT
Top Bottom Ft
Top Bottom Ft
Method
9 SCREEN. Depth Diameter Slot Size Matenal
Top Bottom Ft in in
Top Bottom Ft in in
Top Bottom Ft m m
10. SAND/GRAVEL PACK
Depth Size Material
Top Bottom Ft
Top Bottom Ft
Top Bottom Ft
11 DRILLING LOG
Top Bottom Formation Descnption
0 /52 OVER BURDEN
52 /235 GRANITE
12 REMARKS
Rim/ 0 2 7 n 1 n
mrormation Proc�+cc,n", ,_
uWQ/BOG
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER
L'1J�CJ �irlc ttIr�C J
OF CERTIFIED WELL C NTRAC
10-4-10
SIGNATURE
TOR DATE
DERRICK HEATH SAWYERS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
h
Submit'ewithin 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699=161, Phone . [phone]
IIv/ ,
pfi,• ,4 4 20
'ZO13
Form GW-la
Rev 2/09